The Daisy Network
PO Box 183
End Prescription Charges for People with Long Term Conditions
If you live in England, please write to your MP today, asking them to call for an end to prescription charges for people with long term conditions. It only takes two minutes. With your help we can show politicians that there is widespread support for ending this injustice.
Prescription Charges & Early Menopause / POF
Each member of Daisy Network will have her own unique story of early menopause that will perhaps include feelings of intense sadness, loss, fear and failure. In addition to this, there will probably be the need for medication, sometimes for many years. If this is not enough to cope with, prescription charges add a financial burden, in a system that is outdated and grossly unfair.
This article describes the present system, explores possibilities of change and examines what needs to be done to ensure that women with early menopause (in all its forms and causes) will be properly represented if and when the current system of prescription charges in England are changed..
When the NHS was introduced in 1948, it was a hugely ambitious plan aiming to provide free healthcare for everyone in the UK. The central principles of the NHS were clear, that the health service will be available to all and financed entirely from taxation, so that everybody’s contributions would be paid from their income and therefore related to their earnings. Despite the initial plans of free healthcare, prescription charges of one shilling (5p) were introduced in 1952. Charges were then abolished in 1965 and prescriptions remained free until 1968, when they were reintroduced.
In June 2012, prescriptions are free in Northern Ireland, Scotland and Wales but the cost of a single prescription is £7.65 in England, unless a person is entitled to free prescriptions. Free prescriptions can be obtained by applying for medical exemption certificate (MedEx), usually done through a patient’s GP or hospital doctor, but only if a person is eligible for exemption and the certificates have to be reviewed for renewal every five years.
The exemption rules were decided in the 1960s and were based on a number of factors such as age and medical conditions as shown in Table 1. Other people in England are also entitled to free prescriptions, linked to their benefits. NHS Choices web site has a page ‘Help with NHS health costs’ that lists for the entitlements for free prescriptions at: http://www.nhs.uk/NHSEngland/Healthcosts/Pages/Prescriptioncosts.aspx
Little has changed to the original list of exemptions since the 1960s. It has been much criticised because of its unfairness. Many organisations, including the Macmillan Cancer Support, have campaigned for the abolition of prescription charges in England, so that no one is denied necessary treatment by the inability to pay. The campaign has had limited success with cancer patients in England becoming exempt from prescription charges in April 2009, including those undergoing treatment for cancer and for those with ongoing effects of cancer treatment. Following this change for cancer patients, the government stated in 2009 that ‘over the next few years charges will also be abolished for patients with long-term conditions’. Professor Ian Gilmore, President of the Royal College of Physicians was asked to undertake a review of prescription charges to consider how to define the long term conditions that should be exempted from prescription charges and how exemption from charging could best be phased in.
There was debate about whether prescription exemption should cover only long term conditions or whether all prescriptions should be free in England, as in other parts of the UK. This debate became largely irrelevant as the present Government, while delivering its Comprehensive Spending Review in October 2010 stated that some programmes announced by the previous Government would not be taken forward. Sadly, this included extending free prescriptions in England. An alliance of national charities had been campaigning hard for changes to prescription charging and this u-turn in policy was very disappointing.
How unfair is it?
As you all know, early menopause creates a hormone deficiency; the ovaries do not produce the female hormones, significant for women’s long term health. Young women with an early menopause are advised by the regulatory authorities to take hormone replacement (unless there is a contraindication) up until the average age of the natural menopause – that is between 51-52 years in the UK. The purpose of replacing the hormones (particularly oestrogen) is to treat any unpleasant menopause symptoms but also to prevent early onset of serious health issues such as osteoporosis, cardiovascular disease, Alzheimer’s disease and Parkinsonism. These are all serious health conditions that are potentially very costly in terms of health and social care but can also have high personal costs to a woman’s quality of life and independence as she gets older. We know that many women struggle to pay for their HRT, and some have to choose not to get some prescriptions because of the cost, putting other needs before their own health.
Other hormonal deficiencies are included within the current exemptions, people with an underactive thyroid gland or insulin dependent diabetics have hormone deficiencies are entitled to receive all their prescription free, whether or not a health problem is linked. Both thyroid problems or diabetes are treated by giving hormone replacement in the form of thyroxine or insulin, in a similar way that early menopause is treated with oestrogen replacement therapy.
As if this is not sufficient unfairness, multiple prescription charges are payable when different drugs are supplied. This means that a cyclical HRT incurs 2 prescription charges as the packs contain 2 different drug preparations, oestrogen only for the first part of the cycle followed by oestrogen and progestogen for the remainder of the cycle. Extensive medical studies have been done over many years to produce safe and effective combinations of HRT, suited to younger women and the two different parts of cyclical HRT are a necessary part of this single preparation.
However as women get older, often with lower HRT doses, a continuous combined preparation is sometimes possible. The oestrogen and progestogen are combined and given together continuously and as there is only one single type of tablet or patch, there is only one prescription charge.
For some women it is possible to take hormone replacement therapy as the combined oral contraception pill. In theory a doctor has to mark the prescription with the female symbol (♀) or make it clear that the item is for contraceptive use and then there should not be a prescription charge. However this relies on the support of the GP and also the dispensing pharmacist.
Another way that some young women avoid a part of the cost is by using the Mirena coil for the progestogen part of their HRT and then there is only a single prescription charge for the oestrogen preparation. However for some women neither the pill nor the coil are suitable or acceptable (they are effective contraception, unlike HRT which does not prevent any remaining ovarian function and offers a very slight hope of pregnancy, important for some women).
The number of HRT cycles prescribed at a time seems to be left to the discretion of each individual GP and varies between one to six months for the same prescription charge. There is however precedence with the oral contraceptive pill, that 6 months of treatment is issued on a single prescription, once a woman is settled on treatment.
There are prescription prepayment certificates available and for some women this can help with the cost, either 3 month certificates (£29.10) or 12 months (£104). The 12 month certificate can be paid for with 10 monthly direct debit instalments. The three monthly certificates will save you money if you need four or more prescriptions over 3 months and the twelve month certificate if you need more than 14 in that time. Any unexpected prescriptions will also be included by these certificates.
The Prescription Charges Campaign, an alliance of 24 charities is currently lobbying the Coalition government to abolish unfair prescription charges for people with all long-term conditions. Neil Churchill, chief executive of Asthma UK has set up an e-petition to ask the government to freeze the cost of prescription charges (including the prepayment certificates) until the end of this current Parliament, to increase the awareness and uptake of prescription prepayment certificates and aiming to make prescriptions free for people with long-term medical conditions, including premature menopause.
Should Daisy Network get involved?
If there is a change in government policy on prescription exemption, it is vital that the interests of women with early menopause are comprehensively represented, so there is no doubt about their complete inclusion within new legislation. It can not be assumed that this will happen automatically as discussed below.
The purpose of Professor Gilmore’s report was to review ‘implementing exemption from prescription charges for people with long term conditions’ and he describes in the report two approaches to achieve this. Firstly to expand the list of illness currently exempted or secondly by developing a definition of ‘long term conditions’ so each patient’s health issues would have to fit the definition to qualify for free prescriptions.
If exemption is created through a list of conditions, then early menopause definitely needs to be included. If Daisy Network is not involved, there is a possibility that premature menopause could be overlooked for inclusion. Also the definition of premature menopause needs to be considered carefully thereby excluding any cause of early menopause or absence of ovarian function.
Many long term conditions continue for ever, such as diabetes. However, a woman is no longer considered young to be menopausal from 45 years. So another area for careful thought is how Daisy Network would campaign should there be an inclusion of age restrictions in an attempt to limit exemption. The definition of early menopause is menopause before 45 years and the Regulatory Authority advice about HRT use in younger women is to continue it until the average age of the natural menopause, about 52 years. So should exemption for menopause treatments only be allowed for women starting before 45 years and end for all at 52 years?
Would these restrictions be fair? What about the women who might need HRT in the longer term, after 52 years, for continuing symptom control? And should exemption be limited to HRT? What about women who will need alternative treatments and other continued medication as a result of the effects of early menopause such as alternative bone protective medication? Or how about a 46 year old woman diagnosed as menopausal needing HRT for bone protection until 50 years when she will fit the NICE guidelines for alternative bone medication?
Alternatively if exemption is based on a definition of ‘long term conditions’, then it is again important to make sure that early menopause/absent ovarian function fits within this. There are different ways of defining ‘long term conditions’, such as ‘a disease’, a ‘prolonged course of illness’ or when ‘treatment is required for unpleasant symptoms to help women cope with everyday activities’. The World Health Organisation’s definition is ‘health problems that require ongoing management over a period of years or decades’. Under this system, eligibility would be determined by a doctor against the formally agreed definition. Some doctors could think that premature menopause is not a disease, illness or health problem and if there are no unpleasant symptoms, it is not a long term condition and prescription exemption should not apply.
There needs to be confidence that early menopause in all its forms, is covered by the agreed definition. Professor Gilmore’s suggestion is that the definition is based on ‘duration of the condition (at least 6 months) and the need for some form of continuing management (which might include regular medication; periodic monitoring and review; psychological therapies)’. This seems hopeful and applicable and the inclusion of continuing management is positive as there is variable continuing care for young women with early menopause.
Daisy Network and its members should get involved in the prescription charge campaign. Daisy Network needs to join other charities in Prescription Charges Campaign for changes to prescription charges. As many people as possible should be encouraged to sign the e-petition (closed 2012) and Daisy Network members should encourage their healthcare professionals to support and advertise it.
Although it is unlikely that the government will do a ‘u-turn’ on prescription charge exemption as they have done on other issues recently, Daisy Network members could write to their MPs about the issue of double prescription charges for cyclical HRT and to clarify the rules about how many months of treatment can be given a single prescription might be helpful, once a woman is settled on HRT.
Author: Jan Brockie
Advanced Nurse Practitioner
John Radcliffe Hospital
Oxford OX3 9DU
Article previously published in Update, Summer 2012
Table 1. Free NHS prescription criteria
- 60 or over
- under 16
- 16-18 and in full-time education
- pregnant or have had a baby in the previous 12 months and have a valid maternity exemption certificate (MatEx)
- have a specified medical condition and have a valid medical exemption certificate (MedEx) – see below
- have a continuing physical disability that prevents you from going out without help from another person and have a valid MedEx
- hold a valid war pension exemption certificate and the prescription is for your accepted disability
- are an NHS inpatient
Medical exemption (MedEx) certificates are issued to people who have:
- a permanent fistula (for example caecostomy, colostomy, laryngostomy or ileostomy) requiring an appliance or continuous surgical dressing
- a form of hypoadrenalism (for example Addison's disease) for which specific substitution therapy is needed
- diabetes insipidus or other forms of hypopituitarism
- diabetes mellitus, except where treatment is by diet alone
- myasthenia gravis
- myxoedema (hypothyroidism requiring thyroid hormone replacement)
- epilepsy requiring continuous anticonvulsive therapy
- continuing physical disability that prevents the person from going out without help from another person. Temporary disabilities do not count even if they last for several months
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